Fast-track management of patients undergoing proximal pancreatic resection.

INTRODUCTION: To avoid the risk of complications of biliary drainage, a feasibility study was carried out to determine whether it might be possible to fast-track surgical treatment, with resection before biliary drainage, in jaundiced patients with proximal pancreatic/peri-ampullary malignancy. PATIENTS AND METHODS: Over an 18-month period, based on their presenting bilirubin levels and other logistical factors, all jaundiced patients who might be suitable for fast-track management were identified. Data on complications and hospital stay were compared with those patients in whom a conventional pathway (with biliary drainage) was used during the same time period. Data were also compared with a group of patients from the preceding 6 months. RESULTS: Nine patients were fast-tracked and 49 patients treated in the conventional pathway. Fast-track patients mean (SD) serum bilirubin level was 265 micromol/l (81.6) at the time of the operation compared to 43 micromol/l (51.3; P > or = 0.0001) in conventional patients. Mean (SD) of time from referral to operation, 14 days (9) versus 59 days (36.9), was significantly shorter in fast-track patients than conventional patients (P < or = 0.0001). Length of hospital stay mean (SD) at 17 (6) days versus 22 days (19.6; P = 0.2114), surgical complications and mortality in fast-track patients were similar to conventional patients. Prior to surgery, the 49 conventional patients underwent a total of 73 biliary drainage procedures resulting in seven major complications. Comparison with the group of patients from the previous 6 months indicated that the conventional group were not disadvantaged. CONCLUSIONS: Fast-track management by resection without biliary drainage of selected patients with distal biliary strictures is safe and has the potential to reduce the waiting time to surgery, overall numbers of biliary drainage procedures and the complications thereof.

Sick notes, general practitioners, emergency departments and fracture clinics.

BACKGROUND: General practitioner waiting times are increasing. The two national surveys regarding general practice showed that the number of patients waiting for >or=2 days for an appointment rose from 63% to 72% between 1998 and 2002, with 25% waiting for >or=4 days. The Department of Health recognised that many patients discharged from hospitals and outpatient clinics required to visit their general practitioner for the sole purpose of obtaining a sick note. The report entitled Making a difference: reducing general practitioner paperwork estimated that 518 000 appointments (and 42 000 GP h) could be saved by ensuring that these patients were issued with a sick note directly from hospital rather than being referred to their general practitioner. This practice was to be adopted from July 2001 and included patients discharged from wards as well as those seen in outpatient departments. METHOD: 50 emergency departments and fracture clinics in Scotland and England were contacted to assess whether these guidelines had been adopted. Only hospitals with both accident and emergency and fracture clinics were included; nurse-led and paediatric departments were excluded. RESULTS: Of the 25 Scottish emergency hospitals contacted, 4 (16%) accident and emergency departments and 8 (32%) fracture clinics issued sick notes. This was compared with 5 of 25 (20%) accident and emergency departments and 12 of 25 (48%) fracture clinics in England. Four Scottish and five English accident and emergency departments stated that it was policy to give sick notes, three Scottish and four English departments said that it was policy not to give them and the rest (72% in Scotland and 64% in England) stated that they had no clear policy but "just don't give them". CONCLUSION: The 2001 guidance from the joint Cabinet Office/Department of Health has not been fully incorporated into standard practice in Scotland and England. If all emergency departments and fracture clinics were to issue sick notes to patients requiring >7 days absence from work, this could reduce general practitioner consultations and improve waiting times.

Cell death in cranial neural crest development.

The rhombencephalic neural crest, crucial to the patterning and development of many craniofacial structures, migrates laterally from the dorsal hindbrain, but not as a continuous sheet. We have used a vital dye to demonstrate a discontinuous pattern of cell death in the dorsal midline of the avian rhombencephalon associated with the migration of the neural crest. Whilst cell death commences in the dorsal midline of the presumptive mesencephalon at stage 8, two distinct domains of cell death are apparent in the rhombencephalon by stage 11. The rostral domain lies over primary rhombomere RhA1 and rhombomere rh3, while the caudal domain occurs on the neural midline between the otic vesicles, in the region of rh5. Using a marker for the neural crest, we show that the rostral and caudal domains of cell death correlate with the absence of neural crest migration from rh3 and rh5. Thus segment-specific cell death in the dorsal region of particular rhombomeres may account for their subsequent failure to contribute to the cranial neural crest.

Segmental lineage restrictions in the chick embryo spinal cord depend on the adjacent somites.

We have investigated whether the developing spinal cord is intrinsically segmented in its rostrocaudal (anteroposterior) axis by mapping the spread of clones derived from single labelled cells within the neural tube of the chick embryo. A single cell in the ventrolateral neural tube of the trunk was marked in situ with the fluorescent tracer lysinated rhodamine dextran (LRD) and its descendants located after two days of further incubation. We find that clones derived from cells labelled before overt segmentation of the adjacent mesoderm do not respect any boundaries within the neural tube. Those derived from cells marked after mesodermal segmentation, however, never cross an invisible boundary aligned with the middle of each somite, and tend to be elongated along the mediolateral axis of the neural tube. When the somite pattern is surgically disturbed, neighbouring clones derived from neuroectodermal cells labelled after somite formation behave like clones derived from younger cells: they no longer respect any boundaries, and are not elongated mediolaterally. These results indicate that periodic lineage restrictions do exist in the developing spinal cord of the chick embryo, but their maintenance requires the presence of the adjacent somite mesoderm.

An evaluation of myelomeres and segmentation of the chick embryo spinal cord.

We have investigated whether the neuromeres of the developing chick spinal cord (myelomeres) are manifestations of intrinsic segmentation of the CNS by studying the patterns of cell proliferation and neuronal differentiation. Treatment of 2-day embryos with colchicine does produce exaggerated myelomeres, in confirmation of Källén (Z. Anat. Entwickl.-Gesch. 123, 309-319, 1962). However, this does not imply that myelomeres are segmental proliferation centres: the undulations caused by colchicine are irregular alongside the unsegmented mesoderm, and another mitotic inhibitor, bromodeoxyuridine, has no such effects. In contrast to lower vertebrate embryos, there is no evidence for segmental groups of primary motor neurons in the chick: the earliest motor neurons express cholinesterase, and project their axons into the adjacent sclerotome, at random positions in relation to the somite boundaries. The population of motor neurons projecting HRP-labelled axons into a single somite lies out of phase with both myelomere and somite, and is placed symmetrically about the anterior half-sclerotome. The earliest intrinsic spinal cord neurons, as stained with zinc iodide-osmium tetroxide or anti-68 x Mr neurofilament antibody, show no segmental patterns of differentiation. We conclude that, in contrast to the rhombomeres of the developing hindbrain, myelomeres are not matched by segmental groupings of differentiating nerve cells, and result from mechanical moulding of the neuroepithelium by the neighbouring somites.

Axon repulsion during peripheral nerve segmentation.

The guidance of axons during embryonic development is likely to involve both adhesive and repulsive interactions between growth cones and their environment. We are characterising the role and mechanism of repulsion during the segmental outgrowth of motor and sensory axons in the somite mesoderm of chick embryos. Axons are confined to the anterior half of each somite by the expression in the posterior half of a glycoconjugate system (48 x 10(3) M(r) and 55 x 10(3) M(r)) that causes the collapse of dorsal root ganglion growth cones when applied in vitro. Enzymatic cleavage of this fraction with specific combinations of endo- and exoglycosidases removes collapse activity, suggesting that carbohydrate residues are involved in the execution of collapse. A similar activity is also detectable in normal adult grey matter, suggesting roles for repulsion beyond the development of spinal nerve segmentation.